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Attilio GUARINIU.O.C. EMATOLOGIA
Istituto di Ricovero e Cura a Carattere Scientifico
"ISTITUTO TUMORI GIOVANNI PAOLO II“
BARI
I linfomi di HodglinCriticità nel percorso diagnostico
Hodgkin Lymphoma
ØHistologic hallmark of the disease is the presence of the characteristic Hodgkin Reed-Sternberg (HRS) cells in classical HL and so-called lymphocyte-predominant (LP) cells in nodular lymphocyte-predominant HL
ØHL is unique among all cancers because malignant cells are greatly out numbered by reactive cells in the tumor microenvironment and make up only approximately 1% of the tumor
Ø Most patients can be cured with modern treatment strategies, although approximately 20% still have low therapeutic choices, especially after high-dose chemotherapy and haematopoietic stem cell support
represents the most common malignant lymphoma in young people
Classical HL: Morphology
Nodular sclerosisLymphocyte rich
Mixed cellularity Lymphocyte
depleted
Classical HL: Phenotype
CD30
CD15
Phenotypic Profile of cHL
CD3
PAX5
CD20
IRF4
Nodular Lymphocyte Predominance Hodgkin Lymphoma
Morphologic gray zones in HL and NHLs
PERCORSO DIAGNOSTICO
NOAGOASPIRATIFNAB
Non accettare diagnosi se non su biopsie escissionali
LA DIAGNOSI DI HODGKIN DEVE ESSERE
SEMPREUNA DIAGNOSI “PATOLOGICAMENTE” DOCUMENTATA
a livello di morfologia ed immunoistochimica (biologia molecolare)
DECISIONE TERAPEUTICA
Istotipo
VALUTAZIONE CLINICA E PROGNOSTICA
“TAILORED THERAPY”
goal
Diagnostic Workup
• History • Complete physical examination• Confirmatory workup
Ø Excisional biopsy of the lymph node
Staging Workup
Ø Chest x ray(pa,lat)Ø CT scan thorax,abdomen and pelvisØ FDG PET scan
Ø Complete blood countØ Liver functionØ Renal functionØ Serum albuminØ ESRØ Lactate Dehydrogenase
Ø Bone marrow biopsy (?)
PET Scan has become an integral component of initial staging.
Information provided by PET has been recently incorporated in the lymphoma guidelines for response evaluation after completion of treatment.
Useful for follow up study to evaluate residual masses , dx of early recurrence and predicting outcome.
Ann Harbor Stage
Prognostic Factors
Prognostic factor for Early stage Hodgkins disease
Prognostic factors cont…
Advanced stage hodgkins lymphoma International Prognostic Score
Andrea Gallamini, Martin Hutchings, Luigi Rigacci, Lena Specht, Francesco Merli, Mads Hansen, et al.
PET-2 overshadows the prognostic value of IPS and emerges as the single most important tool for planning of risk-adapted treatment in advanced HL
Management
Eichenauer DA et Al, Annals of Oncology 25 (Supplement 3): 70–75, 2014
Anni 70
• MOPP• ABVD
Anni 80
• MOPP/ ABVD
• Stan• ford V
Anni 90
BEACOPP
Anni 2000
moAb
Biology of Brentuximab Vedotin
Vaklavas C & Forero-Torres. Ther Adv Hematol 2012;3:209-225
Younes A et al. J Clin Oncol. 2012;30: 2183-2189 P
Phase II Pivotal Study of Brentuximab VedotinMaximum Reduction in Target Lesions
94% patients achieved tumour reduction
Modern RT
Weber et al, IJROBP 2009
INRT planning
Koeck et al, IJROBP 2011
20 CT datasets of pts with early unfavorable mediastinal HL
IF-PTV and IN-PTV according GHSG guidelines
Plans:- 3D-CRT (AP-PA)- IMRT (9 equally spaced beams)
Prescription dose: 30 Gy/15 fx
0%10%20%30%40%50%60%70%80%90%
100%
5-y EFS 87%
5-y EFS 89%
5-y EFS 90%
5y- EFS 88%
Evolution of Radiotherapy within the
BEACOPP GHSG Trials
outcomes in HL
Cancer 2014;120:2122-9
HL: Cumulative Survival (Sweden)
Intergroup Trial E2498
5-year FFS values of 82% to 89% were reported with dose- and time-intensified third-generation schedules (BEACOPP), but these improvements have so far not been extended to elderly patients.
Advanced age at presentation is an independent negative risk factor.
…. survival rates for elderly Hodgkin lymphoma (>=60 years), are disproportionately inferior compared with younger patients
Two hypotheses were created to explain these findings:
1) age associated factors: - increased comorbidity,
- reduced tolerability of conventional therapy,
- more severe toxicity
- treatment-related deaths,
- poorer outcome after relapse
2) biologic differences such as • more aggressive histology, • different anatomic distribution of involved sites, and • shorter history of disease (greater frequency of mixed cell disease and
Epstein-Barr virus–related disease)
Hodgkin's Lymphoma in the Elderly: Different Disease in Patients Over 60!By Volker Diehl and Andreas Engert -German Hodgkin Study Group
Linfoma di Hodgkin: 42.000 pazienti
34.000 vivi dopo 5 anni“hodgkin survivors”
• Pazienti giovani• Follow up lunghi• Remissioni dopo radio-chemio terapie intensive
– MOPP / extended field RT / BEACOPP
• Follow up di trapianto autologo e allogenico• Immunosoppressione
Registro AIRTUM 2013
Il rischio di morte per linfoma dopo circa 10 anni dalla terapia, raggiunge un plateau
Mentre il rischio di mortalità dovuta alle complicanze tardive legate al trattamento, continua ad aumentare dopo 10-20 anni e non vi è un plateau
Ng AK et al. N Engl J Med 2010;363:664-675.
le principali cause di mortalità :
– Seconde neoplasie– Eventi cardiovascolari
le principali cause di morbidità :– Disturbi respiratori– Disfunzioni ormonali– Infertilità – Fatigue
►18.5 incremento di rischio di sviluppare seconde neoplasie comparate con la popolazione generale
HL: Complicanze tardive - Neoplastiche
v GIv Polmonev Mammellav Cutev Testa collov Vescicav Tiroide v SNC
Dutch HL cohort 1965-95
cosa si aspettano i clinici dal Registro Tumori
• Integrare i dati prodotti dai registri di “patologia”
• Consentire di seguire nel tempo i pazienti con maggiore continuità
• Consentire stime aggiornate sulla prognosi dei pazienti
• Possibilità di utilizzare i dati per gli studi retrospettivi
Grazie per l’attenzione